Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 017035 (X3) Date Survey Completed 03/17/2022
Name of Provider or Supplier Infirmary Home Health Agency, Inc. Street Address, City, State 851 E I-65 Service Rd S, Suite 1000, Mobile, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
E0000 Based on review of the agency Emergency Preparedness Plan and interview it was determined Infirmary Homecare was in substantial compliance with 484.102 Conditions of Participation: Emergency Preparedness.

G0000 A recertification survey was conducted on 3/15/22 - 3/17/22 with standard level deficiencies cited.

G0536 A review of all current medications
CFR(s): 484.55(c)(5)

A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy.


This ELEMENT is not met as evidenced by:
Based on review of agency policy and procedure, medical record (MR) reviews and interviews, it was determined the agency failed to ensure the medications were current for 4 of 17 MR's reviewed, including Home Visit (HV) # 1, MR # 9, HV # 3 and HV # 7 and had the potential to affect all patients served by the agency.




Findings include:




Agency Policy: Monitoring Medications




Policy Number: 10.008




Revised Date: 5/1/19




Purpose:




To provide a process to ensure continuous monitoring of medications in the patient's home.




Policy:




A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode.




Procedure:




2. All clinicians participating in the patient's care are responsible to assist with the maintenance of accurate patient medication information throughout the episode of care. During the patient's episode of care the following will occur:




a. Through a collaborative process the care team will: Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies...




b. The Physician will be notified of discrepancies and documentation of notification must be evident in the medial record.





4. HV # 7 was admitted to the agency on 2/7/22 with admitting diagnoses of Abscess of The Breast and Nipple and Necrotizing Fasciitis.




A HV was conducted on 3/16/22 at 12:00 PM and the medications were reviewed with the patient during this visit using the medication bottles and the Medication List provided to the surveyor by the facility.




During the review of the medications the following medication was on the list and the patient stated was no longer taking the medication:

Amlodipine 10 mg 1 tablet daily. Discontinued about 3 weeks ago according the patient. A skilled nurse made a visit on 3/9/22 and the medication had been discontinued prior to the 3/9/22 visit and was not removed from the Medication List.




The following medication was on the Medication List and not in the home:

Zinc Sulfate 50 mg 1 capsule daily. The patient stated she should be taking it and ran out and has not gotten any more.




An interview was conducted on 3/17/22 at 9:35 AM with EI # 6, who confirmed the medications should be reviewed on every visit and corrections should be made at that time.










2. MR # 9 was admitted to the agency on 1/15/22 with diagnoses including Epilepsy and Quadriplegia.




Review of the SN visit note dated 2/23/22 revealed the nurse documented "...with Tracheostomy patent and conncted (connnected) to humidified O2 (oxygen)..."




Review of the Home Health Certification and Plan of Care dated 1/15/22, Medications, revealed no order for Oxygen therapy.




In an interview conducted on 3/16/22 at 4:30 PM, EI # 6, Process Improvement Coordinator, confirmed Oxygen was not listed on the medication list provided and there was no order documented for Oxygen therapy.




3. HV # 3 was admitted to the agency on 2/21/22 with diagnoses including Spinal Stenosis and Paroxysmal Atrial Fibrillation.




Review of the Home Health Certification and Plan of Care dated 2/21/22 revealed orders for Physical Therapy 2 x a week for 6 weeks.




A HV was conducted on 3/15/22 at 12:50 PM to observe care provided by EI # 11,Physical Therapist. EI # 9, Patient Care Manager, was also on the HV for observation.




During the HV a review of the medications in the home were compared to the medication list provided to the surveyor on 3/15/22. Red Yeast Rice 600 mg dated 3/8/22 was in the home but not on the medication list. HV # 3 stated he/she had been taking the medication "for about 5 years".




In an interview conducted on 3/15/22 at 1:50 PM, EI # 9, confirmed the medication was current but not on the Medication List.
















1. HV # 1 was admitted to the agency on 2/8/22 with diagnoses including Arthritis Due to Other Bacteria, Vertebrae and Essential (Primary) Hypertension.




A HV was conducted on 3/15/22 to observe Employee Identifier (EI) # 2, Registered Nurse perform a skilled visit. During the visit, the patient's medications were reviewed by the surveyor, EI # 2 and EI # 7, Patient Care Manager and compared to the Medicine List printed for the surveyor on 3/15/22 and the following discrepancies were observed:




Loratadine 10 mg (milligram) tablet, one daily on the Medicine List and per HV # 1, "I don't take it that often. The last time was 6 months ago."




Omeprazole 40 mg capsule, one capsule daily on the Medicine List and per HV # 1, "I stopped taking it 2 years ago."




Ondansetron 4 mg disintegrating tablet, one every 8 hours as needed on the Medicine List and per HV # 1, "I have not taken it in about a year."




Pennsaid 20 mg/gram/actuation (2%) Topical Solution in metered-dose pump topical 40 mg daily as needed on the Medicine List and per HV # 1, "I never had the medicine (in the home)."




An interview conducted on 3/17/22 at 8:30 AM with EI # 1, Administrator confirmed the medication profile was not updated per agency policy.
G0578 Conformance with physician orders
CFR(s): 484.60(b)

Standard: Conformance with physician or allowed practitioner orders.


This STANDARD is not met as evidenced by:
Based on review of Medical Records (MR), agency policies and procedures and staff interviews it was determined the agency failed to ensure physician orders were followed for pulse oximetry, visit frequency, and wound care.




This deficient practice did affect 3 of 17 MRs reviewed including, MR # 4, MR # 8, and Home Visit (HV) # 6 and had the potential to affect all patients served by the agency.



Findings include:



Agency Policy: Plan of Care (POC)




Policy Number: 2.1.007




Revised Date: 12/1/21




Purpose: ...To ensure that physician/authorized practitioner's orders are followed.




...Procedure:




...2. The POC includes:




...All patient care orders...




Agency Policy: The Role of the Physician




Policy Number: 5.011




Revised Date: 11/1/21




...Procedure:




...2...a. The agency's responsibilities to the physician:




I. provides services to the patient only as ordered by the physician.




Agency Policy: Dressing Change Procedure for Central Venous , Midline, and Peripherally Inserted Central Catheters




Policy Number: 10.027




Revised: 10/01/2016




...Procedure:




... 9. Cleanse the site with chlorhexidine (preferred) in a back and forth motion for at least 30 seconds. If povidone-iodine is used, use swabs to apply in a circular motion...





3. HV # 6 was admitted to the agency on 2/28/22 with diagnoses including Hypertensive Heart Disease, Heart Failure, and Encounter for Adjustment and Management of Vascular Access Device.




Review of the HHC and POC dated 2/28/22 revealed orders including for the Skilled Nurse to perform site care for infusion access device to the right arm midline site weekly using sterile technique "cleanse site with alcohol swabs x 3..."




Review of the Visit Note Reports dated 3/8/22 and 3/14/22 revealed the nurse documented the infusion access site was "cleansed with Betadine swabs x 3 followed by alcohol swabs x3..."




There was no order documented to cleanse the site with Betadine.




In an interview conducted on 3/17/22 at 9:30 AM EI # 8, PCM, confirmed there was no order documented for the use of Betadine.










1. MR # 4 was admitted to the agency on 1/14/22 with diagnoses including Aftercare following Joint Replacement surgery, Essential (Primary) Hypertension, and Dependence on Supplemental Oxygen.




Review of the Home Health Certification (HHC) and POC dated 1/14/22 to 3/14/22 revealed documentation of a Physical Therapy (PT) frequency of 1wk1, 3wk1,1wk1 (once a week for 1 week, three times a week for 1 week) and a physician's order for "PT to perform pulse oximetry each visit in order to monitor patients respiratory status."




Review of the PT Visit Note Reports (VNR) dated 1/14/22, 1/19/22 and 1/21/22 revealed no documentation a pulse oximetry reading was obtained.




An interview was conducted on 3/16/22 at 3:51 PM with Employee Identifier (EI) # 7, Patient Care Manager (PCM), who confirmed there was no documentation a pulse oximetry reading was obtained on the above dates.




2. MR # 8 was admitted to the agency on 2/19/22 with diagnoses of Encounter for Orthopedic Aftercare following Surgical Amputation, Type 2 Diabetes with Diabetic Peripheral Angiopathy without Gangrene and End Stage Renal Disease.




Review of Client Coordination Note Report revealed documentation dated 2/17/22 the patient went to dialysis on Monday, Wednesday and Friday of each week




Review of the HHC and POC dated 2/19/22 to 4/19/22 revealed a Skilled Nurse (SN) frequency of once a week for 9 weeks and a physician order for the "SN to assess wound VAC (Vacuum-assisted closure) dressing. No wound care/wound vac orders at this time. Patient to follow up with (physician identified)...on 2/22/22..."




Review of the Client Coordination Note Reports revealed documentation of SN attempted visit on Friday 2/25/22 (week of 2/20/22 to 2/26/22) and Friday 3/4/22 (week of 2/27/22 to 3/5/22). There was no documentation the SN attempted to scheduled a visit for a day the patient was not at dialysis and/or reschedule the SN visit for the weeks of 2/20/22 to 2/26/22 and 2/27/22 to 3/5/22.




An interview was conducted on 3/16/22 at 3:59 PM with EI # 7, who confirmed there was no documentation the SN attempted to complete the physician ordered visits for the above week on a day when the patient did not have dialysis and/or attempted to reschedule the SN visits.







G0590 Promptly alert relevant physician of changes
CFR(s): 484.60(c)(1)

The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered.


This ELEMENT is not met as evidenced by:
Based on review of Medical Records (MR), Agency Policy and Procedure and interviews, it was determined the agency failed to ensure the relevant physician was notified of Wound VAC (Vacuum-assisted closure) treatments not being provided in home.



This deficient practice affected 1 of 5 MR with wounds including MR # 8 and had the potential to negatively affect all patients admitted to this agency.



Findings include:



Agency Policy: The Role of the Physician



Policy Number: 5.011



Date revised: 11/1/21



Purpose: ...To describe the process of notifying the physician of these roles and responsibilities.




Procedure:




...2...a. The agency's responsibilities to the physician:




...ii. provides the physician with accurate, complete, up to date information on the patient.



...notifies the physician of significant changes.


1. MR # 8 was admitted to the agency on 2/19/22 with diagnoses of Encounter for Orthopedic Aftercare following Surgical Amputation, Type 2 Diabetes with Diabetic Peripheral Angiopathy without Gangrene and End Stage Renal Disease.




Review of the Home Health Certification and Plan of Care (POC) dated 2/19/22 to 4/19/22 revealed documentation of "Skilled Nurse (SN) to assess wound VAC dressing. No wound care/wound VAC orders at this time. Patient to follow up with (physician identified)...on 2/22/22..."



Review of the Client Coordination Note Reports revealed documentation of SN unsuccessful attempted visits on Friday 2/25/22 (week of 2/20/22 to 2/26/22), Friday 3/4/22 (week of 2/27/22 to 3/5/22) and Saturday 3/12/22 (week of 3/6/22 to 3/12/22).




Further review of the Client Coordination Note Reports revealed the SN missed visit notifications for 2/25/22, 3/4//22 and 3/12/22 were sent to the patient's primary care physician for the agency.




Review of the MR revealed no documentation the physician identified in the patient's POC following the wound VAC therapy was notified of the SN missed visits on 2/25/22, 3/4/22 and 3/12/22.



An interview was conducted on 3/16/22 at 3:59 PM with EI # 7, Patient Care Manager, who confirmed there was no documentation the physician identified in the patient's POC who was following the wound VAC therapy was notified of the SN missed visits on 2/25/22, 3/4/22 and 3/12/22.
G0682 Infection Prevention
CFR(s): 484.70(a)

Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases.


This STANDARD is not met as evidenced by:
Based on observations, review of agency policies and procedures and interviews, it was determined the agency failed to follow their policy on infection control including hand hygiene (HH), PICC (Peripherally Inserted Central Cather) line care, venipuncture and cleaning of devices.




This deficient practice affected 1 of 2 patients reviewed with a PICC line, including Home Visit (HV) # 1 and and 2 of 7 HV observations for hand hygiene, including HV # 7 and HV # 2 and had the potential to negatively affect all patients served by the facility.




Findings include:




Agency Policy: Hand Hygiene




Policy Number 8.004




Revised Date 5/1/19




Purpose:




To help prevent the spread of microorganisms and infection by cross-contamination and to provide practice guidelines.




Policy:




Staff are required to perform hand hygiene prior to, at specified time points during, and following patient contact...




Procedure:




b. before performing an aseptic task (e.g., insertion of invasive devices,...)




c. after contact with blood,...




d. if moving from a contaminated body site to a clean body site during patient care.




e. after contact with inanimate objects




f. before and after removal of personal protective equipment (PPE)....




Agency Policy: Dressing Change Procedure for Central Venous, Midline, and Peripherally Inserted Central Catheters




Policy Number: 10.027




Revised Date: 10/1/16




Purpose:




To keep insertion sites clean, stabilize catheters and minimize the risk of infection.




Policy:




...Sterility will be maintained throughout this procedure...




Agency Skills Quick Sheet: Blood Specimen Collection: Venipuncture Syringe Method




Published Date: August 2021




31. ...perform hand hygiene, and don clean gloves.




34. Prepare the venipuncture site.




a. Cleanse the site with friction using a gauze pad and 70% isopropyl alcohol solution.




b. Allow the area to air-dry.... Do not touch the site after preparation unless sterile gloves are worn.




Agency Policy: Infection Control Plan




Policy Number 8.001




Revised Date 11/1/21




Purpose:




To enhance the safety and quality of patient care provided by the agency...




Policy:




The agency will establish a comprehensive infection control program...




Program Goals:




...Ensure proper sanitation of medical equipment, devices and supplies...








2. HV # 7 was admitted to the agency on 2/7/22 with admitting diagnoses of Abscess of The Breast and Nipple and Necrotizing Fasciitis.

A HV was conducted on 3/16/22 with EI # 5, Licensed Practical Nurse (LPN) to observe wound care provided.




On arrival to HV # 7's home EI # 5 was at his/her car with the trunk open. EI # 5 had gloves on and was obtaining supplies and bag from the trunk. EI # 5 entered the home with the gloves on used to close the trunk. EI # 5 entered the patient's bedroom and placed barriers on 2 chairs wearing the same gloves used to open and close the trunk of the car. After placing the 2 clean barriers on the chairs EI # 5 removed gloves and sanitized hands and donned clean gloves. EI # 5 placed the tablet for documentation on the dresser in a basket which contained the patient Home Health folder and other patient belongings without placing a barrier.




EI # 5 donned clean gloves after sanitizing hands and removed the old dressing from the right breast area. EI # 5 disposed of old dressing, removed gloves and donned clean gloves and did not sanitize hands. EI # 5 cleaned the scissors and did not remove gloves or sanitize hands and cut the Alginate with scissors and placed on the wound using the same gloves to clean the scissors. EI # 5 removed gloves and sanitized hands. EI # 5 donned clean gloves and cleaned equipment and placed on the clean barrier. Once the cleaning of the equipment was complete, using the same gloves to clean the equipment EI # 5 picked up the clean equipment and placed in the nursing bag contaminating the equipment after cleaning.




An interview was conducted with EI # 9, RN at 12:45 PM who confirmed EI # 5 should have changed gloves and sanitized after cleaning the wound, EI # 9 confirmed EI # 5 should have changed gloves and sanitized hands after cleaning the scissors and opening the Alginate and placing on the wound and prior to touching the clean equipment.




3. HV # 2 was admitted to the agency on 3/9/22 with admitting diagnoses of Essential Primary Hypertension and Unspecified Protein-Calorie Malnutrition.




A HV was conducted on 3/15/22 at 9:07 AM with EI # 3, MSW (Medical Social Worker) to observe care provided.

EI # 3 sanitized hands outside in the patient's yard and placed the bottle of hand sanitizer in pants pocket and then entered the home after opening the screen door and the front door with bare hands.




EI # 3 then went to the patient's room and removed a barrier from the bag, placed barrier on a stack of items in the patient's room and placed the MSW bag on the barrier. EI # 3 did not sanitize hands after entering home and prior to placing the barrier on the stack of items.




EI # 3 spoke with the patient at length and once the conversation was complete EI # 3 documented on the tablet. EI # 3 failed to sanitize hands prior to documentation on the tablet or after completion of the documentation. EI # 3 removed a garbage bag and from the MSW bag and placed the barrier in the partially opened garbage. EI # 3 went to the kitchen to talk with the caregiver and to sign the visit note in the tablet and the used barrier fell out of the garbage bag and on to the kitchen floor. EI # 3 picked up the barrier and again placed in the partially opened garbage bag and threw the bag in the home trash can.




EI # 3 exited the home, removed the bottle of hand sanitizer from pants pocket and sanitized hands and placed bottle back in pocket. EI # 3 was heading to the car and the surveyor asked what EI # 3 was going to do with the tablet. EI # 3 said he/she was going to put it in his/her car, paused and stated the tablet would be cleaned and then removed an alcohol wipe and cleaned the tablet outside in the patient's yard and placed the used alcohol pad in the outside garbage can.




An interview was conducted on 3/15/22 at 10:15 AM with EI # 1, Executive Director, who confirmed hand hygiene was not properly performed during the visit, The tablet should have been cleaned prior to use and after use in the home.






1. HV # 1 was admitted to the agency on 2/8/22 with diagnoses including Arthritis Due to Other Bacteria, Vertebrae and Essential (Primary) Hypertension.




A HV was conducted on 3/15/22 to observe Employee Identifier (EI) # 2, Registered Nurse (RN) perform PICC line access and care and obtain blood specimens. EI # 7, Patient Care Manger (PCM) attended the visit with the surveyor. During the visit, EI # 2 performed HH and opened a sterile package containing individually wrapped sterile packages of supplies to perform PICC line care. EI # 2 placed a sterile barrier on the surface and without donning sterile gloves, removed the sterile packages from the sterile container and placed them on the sterile barrier. EI # 2 then performed HH and donned sterile gloves to open the sterile packages that were placed on the sterile barrier to complete PICC line care. EI # 2 then attempted to obtain a blood sample from the PICC line unsuccessfully and informed HV # 1 that a blood sample would be obtained from a venipuncture.




EI # 2 doffed gloves, performed HH and cleaned the venipuncture site on the left hand with ChloraPrep and then touched the point of entry site with a gloved hand to palpate the vein. EI # 2 then performed a venipuncture attempt without re-cleaning the site. The attempt to obtain a blood sample was unsuccessful. EI # 2 then doffed gloves, performed HH, obtained clean venipuncture supplies, donned clean gloves and cleaned another site on the left hand with alcohol. EI # 2 then touched the cleaned area to palpate the vein and without re-cleaning the site, performed the venipuncture to obtain the blood sample, but was unsuccessful. Prior to ending the visit, EI # 2 cleaned the electronic device used to document the visit and handed the device to HV # 1 to sign the tablet and without cleaning the device, placed it in his/her pocket.




An interview conducted on 3/15/22 at 2:15 PM with EI # 7 confirmed the nurse did not follow their policy for infection control including hand hygiene, PICC line care, venipuncture and cleaning reusable equipment.
G0714 Patient and caregiver education
CFR(s): 484.75(b)(5)

Patient and caregiver education;


This ELEMENT is not met as evidenced by:
Based on Medical Record (MR), Agency Policy and Procedure, and interviews, it was determined the agency failed to ensure the patients and/or caregivers (pt/cg) received education and training appropriate for care.



This deficient practice affected 2 of 5 records reviewed with wounds including MR # 4 and HV (Home Visit) # 7, and 1 of 2 records reviewed with a PICC (Peripherally Inserted Central Catheter) line including HV # 1 had the potential to negatively affect all patients admitted to this agency.



Agency Policy: Patient Education



Policy Number: 3.001



Date Revised: 11/1/17



Purpose: To describe pt/cg interactions designed to promote and maximize patient health and safety.



Policy: The agency plans, supports, and coordinates pt/cg education designed to promote optimal pt health and safety. Patients receive oral and/or written information for this purpose on an ongoing basis while being cared for by the agency.




Procedure:




...3. The pt/cg receive ongoing information specific to the identified needs...including:




b. Pt/cg Plan Of Care responsibilities.




...7. Using the progress/visit note, the clinician documents the level of pt/cg comprehension, pt/cg return demonstration of skill(s) taught...


3. HV # 1 was admitted to the agency on 2/8/22 with diagnoses including Arthritis due to Other Bacteria, Vertebrae and Essential (Primary) Hypertension.




Review of the HHC and POC dated 2/8/22 revealed a Skilled Nurse (SN) frequency of 1WK9 (one time per week for 9 weeks) and orders to instruct pt/cg on administering the following medication Nafcillin 2 GM (Grams) IV (Intravenous) every 4 hours. Pt/cg to flush IV site with 10 ml (Milliliters) of Normal Saline before infusion and 10ml of normal saline and Heparin units/ml 3-5 ml after infusion. Instruct pt/cg regarding infusion procedure, care and use of infusion equipment and signs and symptoms of complications of IV therapy.




Review of the VNR by the SN dated 2/8/22, 2/12/22, 2/15/22, 2/22/22, 3/1/222, and 3/8/22 revealed no documentation of pt/cg return demonstration of accessing of the PICC line, flushing the line and administering Nafcillin via PICC line.




An interview conducted on 3/17/22 at 8:30 AM with EI # 1, Executive Director confirmed there was no documentation of a return demonstration of accessing of the PICC line, flushing the line and administering Nafcillin via PICC line per agency policy.







2. HV # 7 was admitted to the agency on 2/7/22 with admitting diagnoses of Abscess of The Breast and Nipple and Necrotizing Fasciitis.




Review of the Certification and Plan of Care dated 2/7/22 revealed the following wound care orders:




SN to perform/instruct/reinforce patient/caregiver procedure of wound care to RT (Right) breast. Cleanse with Dakins solution, apply silver Alginate, cover with dry gauze, secure with tape using clean technique... change daily. Instruct patient/caregiver signs/symptoms of wound infection and proper disposal of dressings.




Review of the RN (Registered Nurse) OASIS dated 2/7/22 revealed no documentation of the specific education for wound care and no documentation of a return demonstration by the caregiver.




Review of the SN visit notes dated 2/16/22, 2/21/22 and 2/23/22 revealed no documentation of a return demonstration by the caregiver or the patient for the wound care.




Review of the physician order dated 3/4/22 revealed an order for wound care as follows:




Right breast: May shower using liquid antibacterial soap or cleanse with normal saline, rinse well and pat dry, Cover with Silver Alginate. Change dressing daily and as needed. Cover and secure with ABD (Abdominal) pad or absorptive pad equivalent, may use incontinence pad as substitute. Secure in place with Medipore tape or may or may not use sports bra to hold dressing in place ensuring elastic band does not rub against wound.




Review of the SN notes dated 3/9/22 revealed no documentation of the new wound care nor was there documentation of a return demonstration for the new wound care.




An interview was conducted on 3/17/22 at 9:35 AM with EI # 6, Performance Improvement Coordinator, who confirmed there was no documentation of a return demonstration or of specific teaching.

1. MR # 4 was admitted to the agency on 1/14/22 with diagnoses including Aftercare following Joint Replacement surgery, Essential (Primary) Hypertension, and Dependence on Supplemental Oxygen.




Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 1/14/22 to 3/14/22 revealed documentation of a Physical Therapy (PT) frequency of 1wk1, 3wk1,1wk1 (once a week for 1 week, three times a week for 1 week) and a physician's order for "PT to provide/instruct/reinforce to pt/cg wound care to Right Knee Surgical wound daily. Cleanse with Antimicrobial Soap. Cover with Island Dressing.




Review of the PT Visit Note Reports (VNR) revealed no documentation the PT provided education to the pt/cg on how to provide wound care and obtained a return demonstration of the wound care to ensure competency.




An interview was conducted on 3/16/22 at 3:51 PM with Employee Identifier (EI) # 7, Patient Care Manager (PCM), who confirmed there was no documentation wound care education was provided to the pt/cg and a return demonstration was obtained.